NURSING CARE PLAN- Spring 2019 (Two Nursing diagnoses)

Student: ___Lea Al Halabi_________ Date: ___1-2 March 2022__ Unit: ___6th floor - MSU____________

(Total= 6 points)
Patient Initials _____M.D__________________ Bed No. ___406___
Medical history: HTN , DM, Dyslipidemia , bipolar disorder, hypothyroidism.
Case No. _____166273___________ Admission Date ___25.2.2022_________
Nursing Scientific Rationale for Nursing Expected Outcome Nursing Intervention Scientific Rationale for Criteria for Evaluation
Diagnosis (3pts) Diagnosis (3pts) (14pts) Nursing Intervention (14pts) of Expected outcome
Diet: Diabetic (10pts)
, low salt low fat withbilateral
Surgical history: Right hip fracture repair with prosthetic hip , drainage justification (3pts)
At the end of the shift: Assessment:
abscess 1. Patient with acute pain an
in breast , bilateral cataract
Activity: as tolerated 1. Vital signs every 4 increase in BP, HR and
Acute pain Enteritis is inflammation of the
 Patient will be hrs. (temperature, temperature will be present.
small intestine; Enteritis is most
related to
Intravenous Therapy able to describe blood pressure, heart
Medications
often caused by eating or drinking
rate, SPO2). 2. Assessment of pain
inflammation things that
Dextrose 5% 1000cc + 160 aremeq
contaminated with Q 24 hrssatisfactory pain
sodium bicarbonate
control at a experience is the first step in
bacteria or viruses. The germs 1) Amlocard 5mg 1 tab PO 9pm
and smooth 2. 2)Assess
level less than 5 Benta D 10,000 IVpain PO 2/weekplanning
on mondaypain management
and Thursday at 9am
settle in the small intestine and
Allergies on the pain characteristics: strategies. The most reliable
muscle spasmAugmentin
cause inflammation and swelling. 3) Benzhexol 5mg 1tab PO BID 9am - 9pm
scale (0-10). 4)Quality,
Crestor 10mg Location,
2tabs PO 9pm source of information about
The inflammation can also 5)Onset
Euthyrox 100mg 0.5 tab PO Q48hrs 6am
secondary to
Treatments Duration, the pain is the patient.
involve the stomach (gastritis) 6)Precipitating
Lamictal 100mg 4tabs PO 9am
 Patient will or
enteritis,
1. Assesand
vitallarge
signsintestine
(especially(colitis). TheBP )
fever , and 7) Pariet 20mg 1tab PO BID 9am-9pm
show overall relieving factors
8) stilnox 10mg 2tabs PO 9pm 3. The patient’s skin may be
2. symptoms
Perform mayhealth
physical and beginassessments
hours to
evidence
3. byMaintain IVafter
hydration improved mood, 9) Zyprexa 5mg 8tabs PO 9pm pale and cool to touch.
days infection. Symptoms
4. Monitor blood glucose comfort and 3. 10)
Assess
Nebiletfor
5mgsigns
1tab and
PO 9am Restlessness and inability to
the patient may include: Abdominal pain, 11) lorazepamrelating
1mg 1tab
5. Fall precautions coping. symptoms to PO 9pmconcentrate are also some
6. diffuse Diarrhea – (acute
Give medications on timeand severe) , 12) xalipro 10mg 1/2tab PO BID manifestations.
9am-9pm
report pain.
7. Lossinjury
Pressure of appetite
precautions, Vomiting , 13) fluphenazine 5mg 4tabs PO 9pm
Abdominal
8. Blood in the stool.
ATB treatment  Have normal 14) ceftriaxone 2gr IV daily 6am
9. Accurate intake and output vital signs as an 4. Assess
15) the patent’s
metronidazole 500mg IV4. Some
9am- 5pm- 1ampatients may be
Abdominal pain is caused by
pain10.
6/10 Assess ROM and activity level indicative of anticipation for pain satisfied when pain is no
inflammation because the
11. Monitor medications side effects less severe pain relief longer massive; others will
score12.on painMonitor
swelling
mentaland buildup
health of tissue
and stability demand complete elimination
starts pressing against nerve
scale13.
with Follow up on lab test ( lipase, WBC, plts, CRP…)  Patient uses of pain. This influences the
14. Checkendings. This pressure
diet - (diabetic ) sends pain
16. Patient teaching pharmacologica Interventions: perceptions of the
facial signals to the brain, causing
5. Administer pain effectiveness of the treatment
grimacing discomfort. If the pressure l and non- medication when of the treatment modality and
persists, the nerves will regularly pharmacologica needed (Perfalgan) their eagerness to engage in
while
send the signals. l pain-relief further treatments.
palpating strategies. 6. Use non-
References: pharmacological
(mainly on
- Med surgical book : techniques such as
umbilical inflammatory bowel disease page distraction by 5. To reduce pain and provide
2739 encouraging family comfort.
area).
- Uptodate : Evaluation of the visits, watch TV and
adult with abdominal pain relaxation exercise 6. The use of these techniques
such as listening to lessens the stress, tension
music. subsequently decreasing the
pain by gate control therapy.

7. Provide rest periods 7. One’s experiences of pain

to promote relief, may become exaggerated as
sleep and relaxation a result of exhaustion. Pain
may result in fatigue which
8. Provide patient with may result in exaggerated
adequate rest, pain. A peaceful and quiet
comfortable environment may facilitate
environment rest
8. To reduce pain by promoting
comfort and healing quiet
Teaching: environment.

9. Instruct patient to ask 9. Patient will know more about

for PRN medication pain management and the
before pain gets importance of medications of
worse and severe. pain management.
10. Side effects of opioids can be
dangerous and life
10. Teach patient the threatening
important side effects 11. Patients may experience an
of pain medication exaggeration in pain or a
11. Teach the patient to decreased ability to tolerate
Get rid of additional painful stimuli if
 stressors or sources environmental, intrapersonal,
of discomfort or intrapsychic factors are
whenever possible further stressing them

Nursing Diagnosis Scientific Rationale for Nursing Diagnosis Expected Outcome Nursing Intervention Scientific Rationale for Criteria for Evaluation of
(3pts) (10pts) (3pts) (14pts) Nursing Intervention (14pts) Expected outcome with
justification (3pts)
Assessment: Assessment :
1- Observe how the
Bipolar disorder is a mood disorder At the end of my shift, 1- Asking questions
patient uses
requiring
that is characterized by episodes of the patient will: coping techniques
informative
and defense
mania, hypomania and major 1- initiate and answers helps
mechanisms to
identify the
depression. The subtypes of bipolar maintains goal- cope with mood
effectiveness of
changes
disorder include bipolar I and directed and coping strategies
currently used by
bipolar II. Patients with bipolar I mutually 2- Regularly assess
the patient
client for safety.
disorder experience manic episodes satisfying
2- Checking for
and nearly always experience major activities/verbal
Patient’s safety in
3- Regularly monitor
depressive and hypomanic exchanges with the case of bipolar
for the patient's
disorder is
episodes. Bipolar II disorder is others manic episodes
essential during
manifested
marked by at least one hypomanic 2- Patient will the shift
through
episode, at least one major find one or two hyperactivity and
increased agitation
depressive episode, and the absence solitary 3- Prompt
management (i.e.,
of manic episodes. activities that
the patient is a
The exact cause of bipolar disorder can help relieve Interventions: threat to others
1- Administer and to self can be
is unknown, but several factors may tensions and medications avoided) can be
appropriately given as early as
be involved, such as Biological minimize
(Zyprexa, possible if the
differences: People with bipolar escalation of xalipro..) patient's manic
episodes are
disorder appear to have physical anxiety
2- Encourage client detected early.
changes in their brains. The 3- Pt will adhere to talk about
feelings and
significance of these changes is still to therapeutic
emotions
uncertain but may eventually help regimen and
pinpoint causes. take all the
3- Maintain a low 1- Antidepressants
Genetics: Bipolar disorder is more antimanic and level of stimuli in and antimanic
client’s medications may
common in people who have a first- antipsychotic
environment (e.g., be given to
degree relative, such as a sibling or medications loud noises, bright improve patient
light, low- functioning and
parent, with the condition. (Zyprexa,
temperature effectiveness of
Researchers are trying to find genes xalipro..) ventilation) interventions.
that may be involved in causing
4- Assist with ADLs 2- Helps client
bipolar disorder. by giving short, verbalize and
one-step identify the cause
instructions of their actions.
Builds trust and
rapport

3- Helps minimize
Teaching: escalation of
1- Encourage bedtime anxiety
routine that may
include warm bath, 4- Promotes
soothing music and independence
lack of stimulation. while minimizing
Avoid caffeine. the stress of
complex
 2- Teach client instructions.
visualization Patient often have
techniques that difficulty
replace negative concentrating, so
images with positive using one-step
images directions is
important.

Teaching:
1- Promote healthy
sleep hygiene and
encourages rest
and relaxation
which can
decrease mania
and improve
mood.

2- Help improve
client’s self-image
and confidence

Jan 2019/MAS